An estimated 60 million prescriptions each year -- 51.4% of the 115 million prescriptions for opioids -- are written for adults with mental health disorders, according to Matthew Davis, PhD, MPH, of the University of Michigan and colleagues. Of adults who have been diagnosed with anxiety, depression, or other mental health disorders, 18.7% use prescription opioids, compared with only 5% of people without those diagnoses (P<0.001).

"The relationship between mental health and pain is complex, but our study suggests that Americans with mental health disorders are a population to potentially target with strategies that aim to reduce dependency on opioids," Davis told MedPage Today. "Healthcare providers who care for this population should be aware of the high rates of opioid use and be sure to fully utilize non-opioid therapies when appropriate."

The team analyzed data on 51,891 non-institutionalized adults age 18 and up from the nationally representative Medical Expenditure Panel Survey (MEPS) in 2011 and 2013, excluding 2012 data to eliminate duplication of participants.

Because anxiety and depression dominate mental health illnesses in the U.S., the researchers focused their attention on these 2 conditions and used ICD-9-CM codes of 300 (anxiety, dissociative, and somatoform disorders), 311 (depressive disorder), and 296 (episodic mood disorders) to identify people with mental health disorders. They defined an "opioid user" as an adult who filled 2 or more opioid prescriptions in a calendar year.

In the MEPS prescription drug data, the most common oral opioid prescriptions were hydrocodone with acetaminophen, tramadol, and hydrocodone. Opioid users with mental health disorders were likely to be middle-aged, female, white, and unmarried. They received opioids predominantly for musculoskeletal problems, unclassified diagnoses, undefined non-traumatic joint or connective disease (excluding osteoarthritis, rheumatoid arthritis, injury, sprain or strain), or for an unknown diagnosis that was missing in the MEPS file.

The investigators found that, in an unadjusted analysis, patients with mental health disorders had more than 4 times the odds of opioid use than other adults (OR 4.34, 95% CI 3.93-4.77). That association continued even after controlling for sociodemographic characteristics, health status, and other factors: after adjusting for these variables, those with mental health disorders had twice the odds of opioid use (adjusted OR 2.08, 95% CI 1.83-2.35).

Higher opioid use among those with mental health disorders persisted across key variables, including cancer status and various levels of self-reported pain. Among adults with severe pain, for example, 45.3% of those with mental health disorders used opioids, compared to 24.1% of severe-pain patients without mental health disorders.

What accounted for this discrepancy was unclear. "There's some sort of relationship between the patient, the provider and the unique health system they're in," said Brian Sites, MD, an anesthesiologist at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., who was one of the study's co-authors. "It may be that this differential prescribing is a function of the patients' advocacy for themselves because they feel more pain. Pain is psychological, and if you have anxiety, it's possible that ties into it."

It also might be because there is no objective assessment of opioid efficacy, he added. "We need to really, granularly understand what our outcome metrics are with respect to prescribing," he said. "There are various guidelines that suggest that opioid prescribing should be based on functional outcomes such as activities of daily living and physical function, not self-reported satisfaction. It would be a huge cultural change if we were to shift away from self-reported pain scores to more objective measures."

Because mental illness is a prominent risk factor for overdose and other adverse outcomes, improving pain management among this specific group of patients is critical, the authors wrote. Outside experts like Kathleen Brady, MD, PhD, director of the Clinical and Translational Research Institute at the Medical University of South Carolina in Charleston and president of the American Academy of Addiction Psychiatry, agreed.

"This is a population at high risk for suicide, making the risk of opioid prescribing in this population even more concerning," Brady told MedPage Today. "This study emphasizes the need for careful assessment of prescription opioid use and attention to pain management in individuals with mood and anxiety disorders."

The authors noted that their study's cross-sectional, observational design was not intended to demonstrate a cause-effect relationship between mental health disorders and opioid use. The study also was limited because it focused only on prescription opiates, not any concurrent illicit medication use.

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